=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780242982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA KIDS PPEC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2019
-----------------------------------------------------
Last Update Date | 06/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 E. LANE DR. UNITS A/B
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-226-8331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 HARRISON PL
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-960-5045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MOHAMED M ABDELLI
-----------------------------------------------------
Credential | R.N.
-----------------------------------------------------
Telephone | 850-960-5045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3140N1450X
-----------------------------------------------------
Taxonomy Name | Pediatric Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------